Social Media Use Among Nonprofit Organizations in Rural Appalachia

Introduction Social media have changed the landscape of health communication for nonprofit organizations (NPOs). Yet, adoption and use of social media lag among NPOs in rural Appalachia due largely to limited infrastructure development. Methods Semi-structured phone interviews were conducted in January–March 2018 with 21 NPO representatives in an 8-county region of rural Appalachian Tennessee. NPO representatives were asked questions pertaining to social media use and message content, effective communication strategies, and best practices in social media use. Transcripts were analyzed in April–May 2018 using thematic analysis. Results The majority of NPOs had a Facebook page and recognized its promise as a communication tool. However, due to resource constraints, most NPOs used social media as a secondary communication strategy to complement traditional approaches. In terms of messaging, NPOs used social media primarily to share information and solicit donations or volunteers. Representatives identified several obstacles to social media use among NPOs in the region. These included limited organizational resources, community infrastructure, and household resources. Implications Social media are inexpensive communication tools that NPOs in rural Appalachia can use to expand their digital footprint into hard-to-reach populations. Therefore, eliminating the digital divide across the U.S. is an important step toward enhancing rural NPOs’ capacity to serve their communities well. Opportunities for NPO staff to access low-cost professional development and training in the use of social media, specifically for social marketing purposes, are also essential.


INTRODUCTION
ocial media have changed the landscape of health communication for nonprofit organizations (NPOs). Over the past decade, broadband and wireless infrastructure have mushroomed throughout the U.S. resulting in nearly ubiquitous wireless coverage in most cities. Today nearly 90% of U.S. adults are online 1 and seven-in-ten use social media. 2 YouTube and Facebook are the most widely used platforms among U.S. adults, with more than half returning to these sites daily. 2 Many NPOs have taken advantage of this shift in technology and use social media to communicate, share information, and engage in interactive feedback with their target audience. 3,4 Not surprisingly, social media have several advantages over traditional forms of mass communication: cost-effectiveness, broader, rapid reach, ease of dissemination, and potential to build community identity and promote civic engagement. 5 Nonprofit organizations that promote, protect, and improve the public's health can take advantage of social media, as social media have the potential to allow for advocacy and engagement on important health-related issues, 6 which, in turn, can help create a culture of health and improve health outcomes. This is particularly important in Appalachia which has experienced widespread and persistent poverty and poor health outcomes. 7 Yet, adoption and use of social media lag among NPOs in rural Appalachia due largely to limited rural broadband infrastructure, limited organizational resources, and limited exposure to the potential impact of social media on organizational reach and communication efforts. 8 For example, rural populations are less likely to use social media 2 primarily because they have less access to reliable, affordable broadband services. 1 Public perception of need for access to this technology may also be under-represented in rural communities S because of remote location, sparse population, and higher median age compared with suburban and urban communities. 9 Collectively, these factors have limited NPOs' capacity to use social media effectively.

METHODS
Purposive sampling techniques were used to recruit representatives from public health-related NPOs located in an 8-county contiguous region of Appalachian Northeast Tennessee. The IRS Exempt Organizations Select Check online search tool was used to identify NPOs who were located in this 8-county region. NPOs The study was approved by the Institutional Review Board at East Tennessee State University (IRB# c0118.15sd).

RESULTS
NPO Characteristics. Tables 1 and 2 describe the characteristics of the NPOs.
One-third (33.3%) of NPOs in the study had a multi-county service area and onefourth (28.6%) were affiliated with a national organization (data not shown). The majority of NPOs (95.2%) had a Facebook page. However, only 42.8% of NPOs felt they had sufficient resources to use social media effectively and less than one-third (28.5%) had a social media marketing plan (Table 1). Among the most commonly used communication strategies, Facebook was cited as the most effective way for NPOs to communicate with their priority population, followed by direct communication (e.g., word of mouth, personal interactions, referrals, and monthly meetings). Print (e.g., newspaper and mailings), radio, and other forms of social media (e.g., Twitter and Instagram) were identified as the least effective methods ( Table 2). Thematic Analysis. Results from the thematic analysis were organized into four main themes: use of social media as a secondary strategy, messaging, organizational capacity, and rurality (Table 3). Messaging. NPOs used social media mainly to share information and to solicit donations and volunteers. NPOs were far less likely to use social media as an advocacy or community mobilization tool or for creating user generated content.
NPOs that engaged in more interactive messaging specific to programs, events, and initiatives via social media used live video streaming (e.g., Facebook Live), esurveys, and hashtags. Live video streaming was used by NPOs to connect with followers who were unable to attend events in person. E-surveys were described as a tool to get input from the target audience to tailor programming. NPOs used hashtags to connect the audience with important themes within the broader community (e.g., #MeToo). Human interest stories also emerged as a prominent form of messaging among NPOs. Interestingly, NPOs used traditional media (e.g., newsletters and mailings) to share these stories to generate support (e.g., financial and volunteers) for their organization's cause rather than disseminate the information on social media platforms. Thus, remote, rural NPOs relied almost solely on traditional forms of communication (e.g., word of mouth, relationship building, storytelling). For example, NPOs communicated event promotions or schedule changes via word of mouth at local businesses and churches, radio scanners (e.g., akin to police scanners that allow you to listen to two-way radio calls), and text messaging. In terms of obstacles, cultural norms and resource limitations featured prominently in discussions. Specifically, distrust of outsiders and limited interest in adopting new behaviors (e.g., new ways of communicating) were challenges faced by many NPOs. In addition, residents in low-wealth communities had high rates of residential mobility, which complicated NPOs' attempts to reach them by phone or home address. Lack of community infrastructure (e.g., broadband and wireless access, social services) further complicated NPOs' efforts to build strong connections with their priority population via targeted communication campaigns.

IMPLICATIONS
In this qualitative study of NPO representatives in an 8-county region of rural The study has several limitations. Subjective bias, particularly during data analysis, is a concern with qualitative research. Several strategies were employed to minimize bias and enhance the trustworthiness of the study including comparison of analysis by a skilled qualitative researcher, quantitative summary of key findings, and participant feedback to validate findings. Additionally, we did not collect participants' demographic data nor data on NPO characteristics (e.g., size, mission, etc.). These data would have added much-needed context to our findings and subsequent implications and conclusions. Due to the nature of our sampling methodology, participation may have been limited to NPO representatives with the strongest interest in the topic. Lastly, the sample was comprised of senior level staff members (e.g., directors, CEOs, and presidents).
Future studies should include mixed methodologies with a larger sample size, more diverse representation among NPO staff, and content analysis of the NPOs Facebook pages.

CONCLUSION
Congress is working on making high-speed Internet more readily available to rural America. In the interim, NPOs in Appalachia will need to target communication modes available within their service area. NPOs and policymakers can use the findings in the present study to advocate for expansion of broadband and wireless services in rural Appalachia.